Whether it occurs in the first trimester or later in a pregnancy, a miscarriage is always an emotionally traumatic event, sometimes a physically daunting one, and all too often an isolating experience. Adding to the frustration and disappointment of the 800,000 women who miscarry every year, busy obstetricians often lack up-to-date or specific knowledge about the causes and consequences of this profound event. Into this fact-vacuum comes Miscarriage, a book that every physician will confidently recommend and that women hungry for information will seek out. From the chromosomal, illness-related, immunological, and genetic reasons for miscarriage to the diagnostic tests and surgical procedures now available, this authoritative guide reflects the latest medical information on why miscarriages do and don't happen and the best methodologies known for recovery and preparing to conceive again.

Complete with stories from women who have miscarried and reassuring input from a female doctor, Miscarriage also provides substantive advice for coping with the anxiety and depression that often accompany the loss of pregnancy.

Stop by our Pregnancy and Birth cubby and read Dr. Lerner's article titled Stress in Pregnancy.

Miscarriage: Why It Happens And How Best To Reduce Your Risks.

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Welcome to Dr. Henry Lerner, author of Miscarriage: Why It Happens And How Best To Reduce Your Risks. Dr. Lerner replied to StorkNet members' questions about miscarriage and related issues. As many of our members have experienced one or more miscarriages, we know this topic will be one of great value and support. Be sure to take a moment to read Stress in Pregnancy, written by Dr. Lerner.

Christie: I've recently suffered through my third miscarriage. My first two were between 8-10 weeks. With my last pregnancy I was diagnosed with a subchorionic hematoma at 8 weeks. I had severe bleeding and my doctor gave me a 50% chance of carrying the baby to term. I was considered high risk and went to weekly appointments and ultrasounds. At 12 weeks my ultrasound showed the hematoma to be shrinking, the heartbeat was 165, and I had no bleeding or spotting, which was good news. My doctor told me that I wasn't "out of the woods" but my chances for miscarrying were lower since I made it to the second trimester. My next appointment was at 16 weeks and there was no heartbeat. The ultrasound confirmed that the baby had died. I had a D&C performed because of a missed miscarriage. Could the miscarriage still have been related to the hematoma?

Dr. Lerner: Dear Christie: It sounds like you had a horrible time in your attempts to have a baby. I was saddened to read your medical history. Your main question is whether or not the hematoma you had was the cause of your relatively late miscarriage. To me, however, the question should probably be reversed: what was it that caused you to have a hematoma? You now have had three consecutive miscarriages. This means that your chances of their being a specific abnormality causing your miscarriages--as opposed to random chance being the cause--are relatively high. You are an ideal candidate for a recurrent miscarriage work up. The tests involved in such a work up check to see if your uterus is normal size and shape, if your hormone levels are normal, if you have any evidence of infection, and if there is any specific immunologic problem causing you to miscarry. I would advise you to discuss with your obstetrician being tested in this way. If a specific factor is found to be the cause of your miscarriages, it can be corrected. This will of course increase your chances of having a successful pregnancy.

Nikki: Can you tell me if smoking has any cause in miscarriages? I have so many friends that believe it has a lot to do with it. Thank you.

Dr. Lerner: Yes, Nikki, smoking does increase the risk of miscarriage. This has been well shown in multiple studies. The reasons for this are probably twofold. The first is that levels of nicotine and other noxious chemicals in your bloodstream resulting from smoking cause the microscopic blood vessels in the placenta to go into spasm. This decreases blood flow to the fetus. Secondly, smokers have a lower level of oxygen in their blood. The decrease in the amount of oxygen getting to the fetus increases the chances that a miscarriage will occur.

Holly: I have endometriosis and Graves disease. I understand that with endo, my risks of miscarriage are higher. But what about with Graves? My thyroid has been ablated by radioactive iodine and is now being replaced by synthroid. Is there still a chance of a problem? Also, with endometriosis, what causes the miscarriage? Is there a problem with my uterine lining?

Dr. Lerner: Dear Holly: You mentioned that you have two problems, endometriosis and Graves disease. Contrary to what you have been told, it is not in fact the case that endometriosis increases the risk of miscarriage. Endometriosis affects the lining tissues of the pelvis. It has nothing at all to do with the inside of the uterus. It therefore has no effect on the growth and development of the early fetus. Graves disease, on the other hand, is a condition of the thyroid gland which can alter the amount of hormone the gland produces. Low thyroid levels probably increase the risk of miscarriage and certainly increase the risk of mental retardation in the fetus. High levels of thyroid hormone can cause significant health problems to a pregnant woman. Therefore of the two problems you mention it is the Graves disease I would be concerned about. Please ask your obstetrician about this.

Anya: Following my miscarriage last June I have found that my PMS symptoms are more pronounced and begin shortly after ovulation and continue until my period starts again, particularly breast pain. I have also had excessive acne, more than I remember experiencing during puberty. Is this normal?

Dr. Lerner: Dear Anya: You asked whether or not your increase in PMS symptoms, breast pain, and excessive acne following your miscarriage are somehow related to it. Since women often experience changes in how their cycle related hormone levels make them feel, I do not find the changes that you are undergoing unusual. However several of the symptoms you mentioned are seen in a condition called polycystic ovarian syndrome. In this condition the ovary produces an excess of male hormone and throws off the normal ovulation cycle. So rather than your miscarriage having caused your periods to change, it may be that what is currently changing the nature of your cycles had something to do with your having a miscarriage the last time you were pregnant. Please bring your symptoms to the attention of your obstetrician-gynecologist and ask about the possibility of your having polycystic ovarian syndrome.

Melissa: I experienced a missed miscarriage in December of 2002 at 12 weeks. We saw the heartbeat at my initial appointment at 8 weeks. At the time, I was having some difficulty controlling my fasting blood sugars. I had Gestational Diabetes with my daughter, so I was tested early with this last pregnancy. I was started on 10 units of NPH at 11 weeks. My fasting levels were not extraordinarily high--usually around 110 -120ish. Could this have contributed to the miscarriage? I am a bit baffled since we did see the heartbeat at 8 weeks, but then the baby did not survive. I know that often there are no answers as to why a miscarriage happens, but I am hoping to eliminate this possibility if it is even a factor. Thank you!

Dr. Lerner: Dear Melissa: You noted that you had gestational diabetes with your last pregnancy and that your blood sugars were very slightly high at the beginning of this last pregnancy which miscarried. You are wondering whether or not your tendency toward diabetes caused the miscarriage. I think not. Although diabetes does increase the risk of miscarriage, the time frame in which you miscarried falls directly within that which occurs in 20 percent of all pregnancies. Since your blood sugars were in fact not very high, there is no reason not to think that your miscarriage was one of the hundreds of thousands of spontaneous random miscarriages which occur each year in United States. If this is in fact that case, then your chance of having a successful pregnancy the next time you conceive is 80 percent.

Hope: Hello, Dr. Lerner. I am really glad that you are answering our questions. I am 33 and have a three-year-old girl. I have had an early miscarriage at eight weeks October 2002 (I was 32). Last cycle, I got a really early miscarriage. It was my second cycle trying to conceive after the miscarriage. I would not have known it had I not seen an implantation dip and tested positive on HPT 10 dpo because my period came on time. I am now concerned if the two miscarriages have the same cause and if my age or my husband's age (38) has to do with it. Does this increase my chances of another miscarriage or conception? Thanks.

Dr. Lerner: Dear Hope: It appears that you have had two early miscarriages close together. However the fact that you have a normal three-year-old girl means that you are capable of sustaining a normal pregnancy. Not knowing from your note of any other medical problems, it is most likely the case that you have had the bad luck to have the egg and sperm that combine to make you pregnant do so abnormally twice in a row. Since the risk of a miscarriage occurring is 20 percent, the risk of two miscarriages occurring in a row is 20 percent times 20 percent or four percent. This is not that uncommon. The fact that you and your husband are 38 years old only very slightly increases your risk for miscarriage, perhaps to about 23 to 24 percent per pregnancy. My advice: keep trying! If you have another miscarriage then it is time for a miscarriage evaluation.

Tara: What is your opinion on the "luteal defect" and it's role in miscarriage? Some doctors seem to dismiss it, while others believe it is a true problem. Also, can taking progesterone "save" a pregnancy? Thank you.

Dr. Lerner: Dear Tara: You asked my opinion about "luteal defect." This is a wonderful question. I devote most of a chapter to this subject in my book about miscarriages. It is a controversial issue in obstetrics. Some infertility experts feel that certain women cannot make sufficient progesterone after ovulation to sustain an early pregnancy. Therefore these specialists supplement these women in early pregnancy with intramuscular or intravaginal progesterone. Other experts say that there has never been a study showing that such supplemental progesterone decreased the risk of miscarriage. Because of that, and because of not wanting to expose a pregnant woman to any medication unnecessarily, there is an entire school of thought in obstetrics which is opposed to the use of supplemental progesterone. This school feels that the notion of "luteal defect" is suspect and has never truly been shown to be related to miscarriages.

Ali: Is it true that your chance of miscarriage rises if the egg implants late in your cycle (after 6-10dpo)? If so, is there anything you can do to assure early implantation?

Dr. Lerner: Dear Ali: You ask if it is true that the miscarriage rate rises if an egg implants late in a cycle. Since the time it takes from fertilization--which takes place in the middle to outer part of the fallopian tube--until the fertilized egg gets into the uterus and implants in the uterine wall is constant, your question might perhaps better be "does the miscarriage rate rise if fertilization occurs relatively late after ovulation?" The answer to this is yes. There also may be a very slight increase in the risk of birth defects when "late" ovulating eggs are fertilized. Can this be prevented? Only with great difficulty. One would have to watch the eggs maturing on ultrasound throughout the cycle to be able to precisely time intercourse to avoid this happening. Why then is the miscarriage rate and birth defect rate not higher than it is? Because the slight increase in the risk of miscarriage and birth defects in the situation is very very small. Practically, since most fertilized eggs do go on to successful pregnancies no matter when in the cycle they are fertilized, this sort of "micro" timing is not necessary.

Kathy: I am just starting to see a reproductive endocrinologist regarding my two miscarriages. I am 39 and conceived quickly both times (four months and three months). We are now in our fifth month of trying since the last miscarriage. I tested borderline positive for ACA, and I am on baby aspirin, but my RE still thinks my miscarriages are age-related, not caused by that. I am having my FSH tested this month, and am scared to get the results! If I can conceive (I ovulate regularly) even if I have elevated FSH is there a chance that I can still have a "good egg" in there and should keep trying?

Dr. Lerner: Dear Kathy: It appears that you have two issues concerning your trying to conceive and the two miscarriages you have had. One is the fact that you were 39. The other is that you tested positive for anticardiolipin antibody. In terms of your age, the fact that you have had regular periods and that you have conceived twice recently are both in your favor. Yes, it is true that the "quality" of your eggs may not be as high as when you were 25. Still, most eggs in most women in their late 30s and early 40s are healthy and will result in normal pregnancies. The FSH test that you are reluctant to have may in fact be reassuring by showing that your remaining egg follicles are producing sufficient estrogen. In terms of the anticardiolipin antibody testing, it will be important for you and your reproductive endocrinologist to look at the results of all of your immunologic tests in order to determine whether or not there is in fact an immunologic problem present. If there is, such measures as therapy with aspirin and other medications can help decrease your risk of having a miscarriage based on these sorts of problems.

Carrie: My first pregnancy went fine. But our second and third pregnancies ended in miscarriage. Since then we have had three normal pregnancies but, my question is "Is it in the genes?" Is there something that causes a woman to have a miscarriage that could be past down from one generation to another? My mother had a miscarriage her mother also. And all about the same age. We have three daughters and a son. So are there any facts that say why this happens or is it just bad luck?

Dr. Lerner: Dear Carrie: The information in your question tells me that you and your mother and your grandmother have all had miscarriages. But you have also had four children, and since you are here, both your mother and your grandmother must also have had healthy children as well. As I discuss in detail in my book, miscarriages are extremely common. They occur in one in five pregnancies. Most women who have had two or more children have had a miscarriage along the way. Therefore your pregnancy history and those of your mother and grandmother are not at all unusual. You ask if the fact that all three of you have had miscarriages is "in the genes"? Unlikely. If you told me that you and your mother and your grandmother have all had multiple miscarriages, then there might be the possibility that there was a hereditary genetic disorder present. But for women to have one or two miscarriages mixed in with many normal pregnancies indicates that it is much more likely that the miscarriages in your family have been of the "sporadic type" as opposed to be due to chromosomal abnormalities.

Jennifer: What is the most common cause of miscarriage?

Dr. Lerner: Dear Jennifer: The most common cause of miscarriage is the accidental, random miscombination of the chromosomes of the eggs and sperm during fertilization. For fertilization to occur the chromosomes in the nucleus of both the egg and the sperm need to combine and pair off into the 23 pairs--46 total chromosomes--that make up every normal human cell. For the embryo--the combination of an egg and sperm--to have these 23 pairs of correctly ordered chromosomes, a complex rearrangement of genetic material must take place in each fertilization. Miraculously this takes place correctly 80 percent of time--four out of five pregnancies. One out of five times--20 percent of the time--when the egg and the sperm merge, chromosomes do not correctly align. With the new embryo containing abnormal chromosomal material, the fetus can only develop to a certain point. It dies and a miscarriage occurs.

Maureen: I recently miscarried for the first time at 11.4 weeks. It was a missed abortion; the fetal age was around eight weeks at the time I had a d&c. After the birth of my daughter, I was diagnosed as hypothyroid. I have faithfully taken my medications as prescribed, and had my levels checked when I found out I was pregnant so my endocrinologist could monitor my levels more closely during pregnancy. How much impact does hypothyroidism have on maintaining a pregnancy? I'll also be 37 in two weeks, and I know that is a factor in the rate of miscarriage. I truly feel as though my clock is ticking. I guess I just want to know what my chances are, given my age and my thyroid condition, of carrying a second child to term.

Dr. Lerner: Dear Maureen: The role of the thyroid gland in causing miscarriage is controversial. It is known that proper thyroid levels are important for the neurologic development of the fetus. Hypothyroidism, if untreated, can sometimes results in fetal mental retardation. It is also known that abnormal thyroid levels in pregnancy can affect in health of the mother. What is not totally clear is whether or not hyper--too much, or hypo--too little--thyroid increases the risk of miscarriage. Whether or not abnormal thyroid levels do increase the risk of miscarriage, the problem can be obviated by making sure your blood thyroid levels are normal. With careful follow-up by your endocrinologist your thyroid condition should have no impact on your ability to get pregnant, your chances of miscarriage, or your ability to carry a healthy pregnancy to term.

Jennifer: Two years ago, I experienced a very early term miscarriage--so early that I thought it was a normal menstrual period, and did not know I had been pregnant until two weeks after the event. I continued to get positive pregnancy tests for eight weeks afterward, but my next period was right on time. Shortly after the miscarriage, my husband and I decided to try "for real," and I began basal body temp charting. We had no luck for six months. Then, during my next period, I passed a large clot of tissue that looked like nothing I have ever seen before. It was greyish-pink and had a granular appearance. I got pregnant two weeks later. I apologize for the length of this, but I've been wondering for two years if I retained the "products" of that ill-fated conception for six months. (I never had a D&C.) Is this possible, and could it have impacted my fertility? I hope this makes sense. Thanks in advance. -Jennifer

Dr. Lerner: Dear Jennifer: I think it is extremely unlikely that tissue you passed in the past six months after your very early miscarriage was tissue from that miscarriage. There are many sorts of tissue that can emerge from the uterus. That tissue could have been a polyp, a fibroid, or it could have been what is called an "endometrial cast." An endometrial cast is when the entire lining tissue of the uterus comes out all at once during a period as opposed to breaking up and coming out tissue fragments and blood. I therefore think it unlikely that this has had anything to do with whether or not you have gotten pregnant. It is, of course, impossible for me to say this with absolute certainty. But from your description, I think what I said is probably the case.

BJ: I lost a baby at 21 weeks almost two years ago. I was told I have an incompetent cervix. I did however, have several very strong contractions the night before, so the 'silent cervix' theory doesn't apply in this case. I didn't know what was happening (first pregnancy, fairly confident all would be well) but by the time I was flown to the appropriate hospital it was too late, and I had developed an infection, they didn't give us very good odds of making it to 24 weeks. I had also tested + for GBS at nine weeks gestation. Routine test in Canada, I believe. Throughout my pregnancy, there was a small amount of bacteria present in each urine sample. Dr. did not believe it was UTI, but we treated it with antibiotics just in case. I still had this ??? in my urine after the course of antibiotics. Dr. kept saying how unusual this was, but not to worry, so I really didn't. I wonder if this 'mystery infection' as well as the GBS (am also RH-) could be why I had PROM? How can I make sure this doesn't happen to me again, if indeed it was infection that caused this? I just don't accept the incompetent cervix theory, as there was too much pain involved, I just didn't know enough to go in and be checked, a mistake I will never make again. I thought these 'cramps' were just my back muscles protesting as I have always had a bad back, though I soon realized they were unlike any other cramps I've ever had, realized it too late. Thank you for your time.

Dr. Lerner: Dear BJ: I have to disagree with your assessment of what happened. The fact that you had some pain just before your 21 week miscarriage does not mean that you had preterm labor as opposed to cervical incompetence. Once an incompetent cervix, because of its inherent weakness, dilates to a certain point, delivery becomes inevitable. At that point you will have pelvic pain. It seems most likely from your description that you did in fact have an incompetence cervix, your cervix opened up, you were about to pass the fetus, and the pain began then. The fact that you were positive for beta strep does not mean that you had an infection. Beta strep is a "carrier state"--not an infection. B-strep is a normal organism in 10 to 20 percent of all women. Beta strep carrier state is not treated during pregnancy because it has been shown that it is almost never eradicated by doing so. Beta strep carrier state is only treated in labor to prevent transmission to the fetus. However if a woman's urine is found to be positive for beta strep, this is evidence of a urinary tract infection and she will be treated. Given your history, the key thing in any future pregnancy you have is for you and your doctor to evaluate whether you need to have a stitch placed in your cervix in early pregnancy to prevent the recurrence of what sounds like cervical incompetence. Wishing you well.

Melissa: I am 12 weeks along into my third pregnancy. My first was a live birth and the second ended in D&C at 9 1/2 weeks because the embryo quit developing around 7 1/2. This pregnancy I had some of the same "warning signs" I did with my last pregnancy at the exact same time (sudden loss of symptoms, light pink to red bleeding, cramping, and severe migraines) but at 12 weeks I'm still moving forward. When this pregnancy began to look like a threatened miscarriage, I demanded my OB put me on Prometrium vag. suppositories although she thought it wasn't necessary and still doesn't think it's what has made a difference although I'm convinced that the progesterone drop they saw when they did a blood test proves otherwise. I went in 48 hours at week 5 1/2 from 24 to 16. So my question to you is, what are your thoughts on progesterone supplements helping to keep a miscarriage from occurring? Why is this such a questionable solution for so many doctors and why haven't tests been done to prove it's worthiness at saving a pregnancy. The maker of the drug doesn't even label that as a use. I'm personally convinced that I would have lost this pregnancy without it, but find it frustrating to not have professional support of its merit.

Dr. Lerner: Dear Melissa: Your question is a good one and involves an area of tremendous controversy. I spend most of a chapter in my book discussing it. The facts are these: there is no evidence to show, despite multiple studies looking for it, that women who use progesterone to "support" an early pregnancy have a lower rate of miscarriage than women who do not use progesterone. The fact that you had one pregnancy that miscarried without progesterone and one that is going forward with progesterone is not, unfortunately, sufficient evidence that it is progesterone that made the difference. These results could just as likely have happened by chance. When large numbers of women have been evaluated looking at just this question, no difference was found. So it's not that doctors have not looked to find an answer to this question. This question has been studied and the answer appears to be that the use of progesterone does not make a difference. For further information please refer to my extensive discussion of this subject in my book.

Angie: : I have had two miscarriages, both at 22 weeks. With my second one I had a cerclage put in but the doctors said that one of the babies had chiro (they were twins). What can I do to obtain my all time goal of being a mother? I also have been diagnosed with PCOS recently. I have very high insulin levels and have taken medication for it.

Dr. Lerner: Dear Angie: The fact that you had two miscarriages both around 22 weeks indicates that you most likely have either cervical incompetence or an ongoing hereditary chromosomal abnormality. Unfortunately I do not know what you mean by "chiro." Could you mean "chorioamnionitis" which is an infection of the fluid around the babies? The fact that you have polycystic ovarian syndrome does also slightly increase your risk of miscarriage. However, there are several effective ways of dealing with this problem. These involve either inducing ovulation with Clomid or eliminating the cause of polycystic ovarian syndrome--which appears to be insulin insensitivity--by use of a medicine called metformin. Both of these medications help overcome the difficulty ovulating many women with PCO experience.

We have two similar questions so we're posting them together: Christina: I am dealing with a lot of stress now that I am pregnant that is completely unexpected. Can this cause miscarriage? ... And: Dannie: I have read in many books and articles that stress may play a part in Miscarriage. Yet my doctor assures me that my miscarriage is not a result of stress. No tests were ever done to find a cause, but I was under extreme stress at the time of mine. My doctor told me that in fact stress doesn't have anything to do with a miscarriage. How true is that?

Dr. Lerner: Dear Christina and Dannie: There has been much controversy as to whether or not stress has any effects on pregnancy or miscarriage. Based on studies of pregnant women during the two world wars, it appeared that stress in and of itself did not increase the risk of miscarriage or birth defects. There was found to be a correlation between extreme stress and preterm delivery. New research, however, seems to indicate that there are certain hormones produced by women under extreme stress which may increase the risk of miscarriage, preterm labor, and other pregnancy complications. While more knowledge is being obtained about this relationship, it is important to remember this: If stress does increase the risk of miscarriage, the rate at which it does so must be very small or else this association would have become obvious years ago. Therefore although the stress you are currently dealing with will likely make you feel uncomfortable, it is not very likely to have any significant impact on whether or not you have a miscarriage.

Johanna: I was 11 1/2 weeks pregnant when I miscarried. The doctors concluded that it was a blighted ovum (which I understand means a placenta but no baby ever formed.) If you can hear a baby's heart beat at six weeks, why did I miscarry at almost 12? I was feeling pregnant the whole time (except for the last week). If a baby never formed, wouldn't that mean I should have miscarried after five to six weeks? Could it have been something different?

Dr. Lerner: Dear Johanna: Your confusion over the term "blighted ovum" is understandable. All that "blighted ovum" means is that a miscarriage has occurred so early that no clearly defined fetal tissues have yet formed. If a fetal heart was seen on ultrasound examination at six weeks gestation--it would have been impossible to "hear" the fetal heart at this stage--then the term "blighted ovum" does not really apply to your early miscarriage. Since most early miscarriages are caused by chromosomal miscombination, the resulting defect in the genetic plans for fetal development can occur any time in the first trimester. Thus whatever was not normal with your fetus could have caused its death sometime after the development of the fetal heart. You could have seen the fetal heart on ultrasound and yet, unfortunately, the fetus could have had some other major developmental defect which went on to cause its death and subsequent miscarriage.

Dawn: My first pregnancy ended in miscarriage at eight weeks. The attending doctor told me that one out of three pregnancies end in miscarriage (maybe he thought it would make me feel better, but it just made me more nervous.) Is that true? If not, what is the statistics on that? Thank you very much.

Dr. Lerner: Dear Dawn: I think the statistics your doctor quoted you are slightly off. In fact, one in five pregnancies end in a miscarriage. For women who are slightly older--35 to 40 years old--the miscarriage rate is probably one in four, or 25 percent. Only in women who or 42, 43, or 44 years old, would I think the miscarriage rate to be as high as 33 percent, or one out of three pregnancies.

Shelli: I got pregnant seven years ago with IVF twins, and needed progesterone to sustain the pregnancy, and even then the levels kept dropping even with suppositories. I got pregnant naturally for the first time in August and then lost the baby in October, it had died at eight weeks. Should I have been on progesterone, the levels were never tested would that have sustained the baby? Should I go on it if I am ever lucky to conceive naturally again?

Dr. Lerner: Dear Shelli: You have asked a very common and very interesting question concerning the role of progesterone in pregnancy. As I have stated in a previous answer, this is an area of great controversy in obstetrics. The bottom line is that progesterone supplementation may be necessary when ovulation is artificially stimulated by infertility medications. However there is no evidence to show that progesterone supplementation decreases the risk of miscarriage in spontaneous conceptions. This is despite multiple studies having looked at this question over many years. So the fact that your spontaneous pregnancy miscarried likely has nothing to do with what your progesterone levels were or whether they were checked. Think of it this way: If there was something so wrong with your pregnancy that the placenta was not making the correct amount of progesterone, why should we think that the fetus itself would have been healthy? When insufficient progesterone is made in a spontaneous pregnancy there is usually a reason.

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